Case Study: Diagnosis and Management of Gouty Arthritis in a Middle-Aged Male
A 33-year-old male with fever, chills, joint pain, and inflammation in knees was diagnosed with Gouty Arthritis. Detailed medical history, vitals, test results, and treatment with specific drugs like Tramadol, Diclofenac, and Febuxostat were provided. Assessment revealed elevated uric acid levels, and the plan included antipyretics and caution with opioid use in NSAID combination.
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Presented by: Krishnendu Ray Assistant Professor
PATIENT DETAILS: A 33 years old male patient was admitted on general medicine ward on 13-11-19 and got discharged on 15-11-19 and the length of the stay of the patient was 3 days.
CHIEF COMPLAINTS: Fever, Chills, Pain in joints, Inflammation in knees.
MEDICAL HISTORY: Nill. SOCIAL HISTORY: Alcoholic.
VITALS: DAY1 DAY1 DAY2 DAY2 DAY3 DAY3 PARAMETER PARAMETER 1.B.P [mm Hg] 2.R.R 3.P.R 120/80 140/90 120/90 24 82 22 74 22 72 [Bpm] 4.TEMP 98.6 99.9 98.9
PARAMETER PARAMETER OBSERVED OBSERVED VALUE VALUE NORMAL NORMAL VALUE VALUE Hb 8.3g/dl 85.9 13-16g/dl 80-96 Mean cell volume Creatinine 0.5mg/dl 0.6-1.2 mg/dl Total RBC 3.27m/cc 4.5-6m/cc Mean cell Hb PCV Uric acid 24.5% 22.7% 8.9mg/dl 27-32% 40-52% <6mg/dl
SPECIFIC TEST: Examination of synovial fluid from inflammed joints: Presence of ureate crystals. DIAGNOSIS: GOUTY ARTHRITIS.
TREATMENT: DRUG DRUG DOSE DOSE FREQ FREQ R.O.A R.O.A DAY DAY 1 1 DAY DAY 2 2 DAY DAY 3 3 I. Tramadol 50mg Bid I.V + + + Diclofenac 30mg qid Oral + + + T.Omeprazole 40mg Bid Oral + - - T.Febustat 40mg O.d Oral + + + Vit c supplement 90mg O.d Oral + + +
SUBJECTIVE: Fever, Chills, Pain in joints, Inflammation in knees.
OBJECTIVE: Hb - 8.3g/dl Total RBC - 3.27mm/cc PCV - 22.7% Mean cell Hb - 24.5% Uric acid - 8.9/dl
ASSESMENT: No drug interactions found. Uric acid levels are elevated.
PLAN: Prescribe antipyretic to reduce fever. Opiod analgesics should not be consumed with NSAIDS, so change the time of administration. NSAIDS treatment should be discontinued after symptoms are resolved. Prophylactic anti inflammatory therapy is recommended. Prescribe iron supplements to increase haemoglobin.
Ice packs can be helpful in relieving pain and inflammation.
